KENNETH THORPE: Want better health coverage? Change your zip code

Kenneth Thorpe, Partnership to Fight Chronic Disease

Published
4:00 pm CDT, Thursday, June 9, 2016

One of the nation's largest Medicare contractors just decided that it won't cover a proven new heart monitor that tracks signs of heart failure. That's terrible news for millions of Americans suffering from cardiac disease.

It's also a terrifying example of what happens when contractors -- and the actuaries who rule their books -- take healthcare decisions away from patients and their doctors. Indeed, Medicare's reliance on private contractors to run the program exacerbates the nation's health disparities by denying Americans in certain states access to life-saving medical advances.

The Medicare administrative contractor, or MAC, that rejected this monitor is Novitas. In 11 states, including Texas, plus the District of Columbia, Novitas processes and pays Medicare claims. Ultimately, it's up to MACs -- not doctors or even Washington policymakers -- to decide if new treatments and technologies will be covered by Medicare in their jurisdictions.

All too often, the process of local coverage determinations is unpredictable and incoherent -- and can leave many Americans without access to vital care.

The heart monitor decision is illustrative.

The implantable device, CardioMEMS, recently received approval from the Food and Drug Administration after extensive trials. But Novitas, citing a lack of clinical data, ruled against covering the device. So Americans living within its jurisdiction won't have access to the monitor, even though it has been shown to lower hospitalization by 48 percent.

Other devices are at risk, too. Last fall, CGS Administrators, a MAC which covers medical equipment in 38 states, put forward a plan to deny access to certain prosthetics.

In many cases, access to these devices and treatments could save and lengthen lives and curb healthcare spending. But current procedures for coverage decisions have created a healthcare landscape where certain services and treatments are available and covered by Medicare in one state but unavailable in the next.

A recent report by the Inspector General of the U.S. Department of Health and Human Services confirmed this discrepancy and raised concerns. The report examined coverage decisions for services under Medicare Part B, the part of the program that covers outpatient care. The report found that of the 7,500 submitted procedure codes, the methodology used to identify medical procedures, half were subject to the decisions of local contractors.

There's a particular irony in the case of CardioMEMS. This is a device that keeps people out of the hospital -- an important nationwide goal established by the Medicare program. Medicare now penalizes hospitals with excessively high readmission rates, by docking reimbursement rates for Medicare services by as much as 3 percent.

More than 54 percent of the hospitals in Texas within the Novitas network have been penalized for excessive readmissions. Covering more devices could help lower readmission rates, bringing significant savings to the nation's healthcare system and preventing hospital stays for people living with heart failure.

Advances in medical technology are lengthening lives and beating previously untreatable diseases. Americans suffering from heart disease, or any other treatable ailment, should not be denied a chance to benefit from these advances based on where they live.

Kenneth E. Thorpe is professor of health policy at Emory University and chairman of the Partnership to Fight Chronic Disease.